A neglected Bosworth fracture-dislocation complicated by diabetic neuropathy: a case report

Abstract

The Bosworth fracture-dislocation is an exceedingly rare and complex ankle injury characterized by the entrapment of the proximal fibular fragment behind the posterior tibial tubercle. Due to its anatomical configuration, this injury is typically irreducible by closed means and poses a significant diagnostic challenge. We present a unique case of a neglected Bosworth fracture in a 62-year-old female who presented three months after the initial trauma. Upon her delayed presentation, clinical examination revealed a fixed external rotation and equinus deformity of the right ankle, while radiographic and computed tomography (CT) evaluations confirmed a chronic Bosworth fracture-dislocation. A key feature of this case was the patient’s newly diagnosed uncontrolled diabetes mellitus and associated severe peripheral neuropathy. It is highly probable that the loss of protective sensation masked the typical pain response, allowing the patient to intermittently bear weight and leading to a neglected clinical picture consistent with early Charcot neuroarthropathy. Given the chronic nature of the dislocation and the significant joint destruction, anatomical open reduction and internal fixation were no longer feasible. Instead, a salvage procedure consisting of fibular repositioning and ankle arthrodesis with an intramedullary nail was performed to provide skeletal stability and prevent further complications such as ulceration or limb loss. This case highlights how comorbidities like diabetic neuropathy can alter injury perception, leading to delayed treatment and the necessity for more radical surgical interventions like arthrodesis.